Ruminations by a non-academic general surgeon from the heart of the rust belt.

Wednesday, December 12, 2007

Inguinal Hernia

We see a lot of referrals for inguinal hernia in private practice. Other than lap chole, inguinal hernia repair is the most common operation done in America. What people don't realize is the anatomic complexity that must be understood and navigated when undertaking the repair. Surgical residents don't really "figure out" groin hernias until sometime in the third or fourth year. It requires thinking three dimensionally in a small space. Suddenly, something clicks and everything makes sense. You could watch three colon resections and have a good handle on how to do the case, but inguinal repairs need to be watched over and over. It's very subtle.

Given that surgeons have a hard time grasping groin hernias, it's no surprise that patients struggle to articulate what is happening to them. I hear various descriptions of something going on that isn't quite right. "I got a problem 'down there'". "My ball is swollen." "Something keeps jumping out when I cough." "It pinches when I work." "Something keeps going in and out." "My doctor says I got a hernial." I've heard it all. So let's do a question and answer session and clear some things up.

What is an inguinal hernia?Hernia comes from the Latin for "rupture". It's basically a defect in the strong fascial component of the abdominal wall. The inguinal canal contains the spermatic cord and its associated blood vessels. The testicle starts out embryologically up near the kidney. As the fetus develops, it migrates from the abdominal cavity through the abdominal wall via the inguinal canal into its final resting place in the scrotum. The membranous connection to the peritoneal cavity is called the processus vaginalis. If this remains patent, one is susceptible to indirect inguinal hernias. Indirect inguinal hernias occur lateral to the inferior epigastric vessels. Conversely, direct inguinal hernias are not congenital. They occur through attenuated tissue medial to the inferior epigastric vessels. These are the hernias of "wear and tear" and heavy lifting. Differentiating direct from indirect is not always possible pre-operatively, but the approach is the same for each one.

Why should I worry about my groin hernia?Several reasons. Number one, you worry about bowel slipping into the hernia and getting trapped (incarcerated). This can lead to bowel obstructions and even gangrene of the affected bowel. Fixing hernias in the setting of bowel obstruction or ischemic intestine can be quite problematic and morbidity/mortality rates are substantial. So it's wise to consider repair on an elective basis; before such complications arise. Number two, hernias don't improve with time. They get worse. If you're having a hard time now, it's not going to be any better in two years.

So should all hernias be fixed? This is a little controversial. Asymptomatic inguinal hernias can probably be watched in most men. There's a good study from the Hines VA in Chicago that addresses this. Any symptomatic groin hernia should be repaired. Symptoms can vary from patient to patient. Anything from a dull ache at the end of a work day to a sharp, acute pinch with lifting can be described. Any hernia that you see bulging yourself should be repaired. All hernias in women should be repaired. Hernias in children ought to be repaired with high ligation of the sac.

How are you going to fix my hernia?Inguinal hernia repairs have undergone quite an evolution over the past hundred years or so. Bassini perfected a technique that still bears his name in 1887. This involved suturing the conjoint tendon/internal oblique/transversalis musculature laterally to the inguinal ligament. McVay modified the technique by adding a relaxing incision in the rectus fascia and utilizing Coopers ligament for some of the sutures. The Shouldice repair is another tissue repair that closes/reinforces the inguinal canal in four running suture layers. The problem with all of these tissue repairs, however, can be summed up in one word: Tension. Tissues brought together under tension are doomed to breakdown. Recurrence rates with tissue repairs are as high as 50-60%. Tension also substantially increases post-operative pain. Patients were often hospitalized for 4 or 5 days after hernia repair in the days prior to the use of mesh.

So you use mesh?Absolutely. Mesh allows for tension-free repair of the defect. Tension free repairs have reduced recurrence rates to around 1-5%. Post operative pain is now manageable on an outpatient basis; 95% of patients go home the day of surgery.

Isn't mesh dangerous? What about recalls?Mesh infection rates are usually quoted as being less than 1%. I do these operations sterilely in the OR and peri-operative antibiotics are always given. The Kugel Composix Patch was the one recalled. I never used that particular brand.

What are the kinds of mesh repairs?There's the Lichtenstein repair, the Plug and Patch technique, and the pre-peritoneal repair. All of them involve returning any indirect sacs to the preperitoneal space and reinforcing the inguinal floor with a non-absorbable, inert mesh. For open repairs I generally utilize the Modified Millikan technique (a Robbins/Rutkow modification) using a plug inserted through the internal ring into the preperitoneal space and fixed to the internal oblique, conjoined tendon and inguinal ligament with non-absorbable sutures. The floor is then reinforced with an onlay patch.

What about laparoscopic repairs?There are two techniques to consider when discussing the laparoscopic approach: TEPP and TAPP. TEPP stands for total extraperitoneal patch. TAPP stands for transabdominal peritoneal patch. The best way of thinking about the laparoscopic approach is to imagine a hole in your windshield. Patching that hole from the outside is comparable to what happens during an open, anterior approach. The laparoscopic approach is like fixing that hole from the inside of the car. Same end result, just a different way of approaching it. We now have good evidence that laparoscopic inguinal hernia repair is comparable to the open approach in terms of recurrence rates. Moreover, there is also accumulating evidence that patients recover much quicker with the laparoscopic approach and are able to resume activities sooner. The problem is that you have to give the patient general anesthesia for these operations. It's also more expensive.

So who do you offer laparoscopic repair to?Recurrent hernias and bilateral hernias are the best candidates for the laparoscopic approach. You don't want to have to dissect through previously disturbed tissue planes in recurrent hernias; the laparoscopic approach allows one to address the defect through fresh, undisturbed tissue. Bilateral hernias can be fixed simulataneously through the same laparoscopic incisions without much added operative time. I also consider laparoscopic hernia repair at patients request. Young athletes who want to get back to training as soon as possible seem to bounce back quicker with the laparoscopic technique. For run of the mill, unilateral inguinal hernia, I find it hard to justify laparoscopic repair. It's costlier and cardiovascular events are certainly increased anytime you subject a patient to general anesthesia. The open approach has a low recurrnce rate, allows the patient to go home the same day, and utilizes fewer resources. That's a tough combo to ignore.

How am I going to feel afterwards?You're going to be sore. I usually write for prescription-strength pain medications for the first three to five days. Everyone recovers a bit differently. Some guys are ready for work in three days. Others need a bit more time. Some other things to expect: scrotal swelling, numbness over the incision, burning with urination, and prickling sensations that radiate into the upper leg. Almost universally, these issues are self limited and will resolve with time.

Any restrictions afterwards?No lifting anything more than 25 pounds for at least three weeks. Other than that I encourage resumption of normal activities as soon as possible. At six weeks, the scar tissue that forms will be about as strong as it ever will be, so until that time avoid power lifting or any similar ultra-strenuous activities.

18 comments:

You're absolutely correct about the learning curve. I can't count how many hernia repairs I "did" in training before I really understood the anatomy. I think it takes helping someone else do a few to solidify the knowledge. And it sounds like your approach is a lot like mine, in that I prefer open repairs for most situations, for the cost, the speed, and the comparable post op discomfort. I reduced or removed the sac, opened the transversalis fascia at the internal ring and slid a rectangular patch of marlex into the propertioneal space. Over time I used a larger and larger patch, widely covering the inguinal floor, and made a lateral slit to allow passing a thin "leg" lateral to the cord. Directed it flat with a couple of deBakeys, sutured only with a single stitch used to re-close the transveralis, grabbing a bite of the mesh below. The whole thing took only 15 minutes or so. My post op instructions were to avoid things that made it hurt more. The only infection I ever had was in a guy with dermatitis in the area, in whom I placed a mesh anteriorly, a la Lichtenstein. Never did it again.

aving thsi type hernia seems to be popular in our family. both my son's were born with one of these hernias that were fixed by open surgery when they were a few months old. This was a few decades ago. My grandson who is now 1 yr old was born with bilateral hernias. He was a premmie so he also had a few other problems. He had bilateral lap surgery when he was 4 months old. All of them had no problems following surgery and I dont even remember that they had much pain or needed prescription pain meds. My sons were hospitilized for several days but grandson came home the next morning.

Do you also do fundoplication surgery with hiatal hernia repair? If so, do you use mesh with them and is the results typically better with lap or open? husband had this surgery done locally with an open procedure using mesh for the hernia repair. I had mine done at a big out of town acedemic surgery center not using mesh but rather he fixed my hernia with 3 stitches. Husband had his done in 1994 and yet today he has had no problems with reflux and his hernia has not recurred. mine however was a completely failed surgery within 6 months. My hernia was back and my wrap had also failed. So to me it seems open is better, as is repair with mesh but I wondered if this is the norm or if lap is usually a good surgery for this.

Doc Schwab- Sounds like a Nyhus-type pre-peritoneal repair, only from the standard anterior approach; I like the idea. Do you open the entire floor/transversalis fascia? Sounds similar to that prolene hernia system product.

Anon- Hiatal hernias are a different animal. Hiatal hernia in and of itself is not an indication for an operation. Hiatal hernias are often associated with GERD and patients with refractory GERD are candidates for Nissen and hiatal hernia repair. Nowadays, the standard of care is to perform these fundoplications laparoscopically. Most hiatal hernias can be tightened at the same time using interrupted sutures. Large hiatal hernias and especially paraesophageal hernias usually require some sort of prosthesis for coverage. Failure rates for Nissens usually run 10-25% depending on the surgeon. it ain't a perfect solution.

I only open a very small amount, just enough to slide the mesh under and manipulate it into place, after a finger sweep to clear the properitoneal space. It's just, essentially, enlarging the internal ring.

My boyfriend has had 2 inuinal left and right hernia surgerys over last 2 years. Since the last surgery which was about 8 months ago his semen appears very thin and has difficulty refraining from ejaculating. Please let us know if there is anything he can do?

Hi, I had a bilateral ingunial repair 3 weeks ago (laproscopic) and now I can feel a lump on one side - I'm concerned as it feels like it's about to re-occur or already has, it's not causing particular discomfort but I am going back to the doc to check that it's ok. Some say this is just scar tissue/swelling and it's normal - could this be the case? Thanks

Had open on the left 10 years ago and laproscopic repair on the right 5 days ago. The open repair was extremely painful compared to the laproscopic which hardly hurt at all. I took pain meds only the day of surgery and nothing thereafter.I actually got on a plane and flew the next day with very little discomfort. I do have swelling in the hernia area after the laproscopic but I assume it is from the space created by the balloon and fluid filling it. I also like the no restrictions. I took off 3 weeks this time because of the pain with the previous repair but certainly didn't need it.

I had open incision for an inguinal hernia exactly two weeks ago. The tension free mesh was used. The incision site feels good, and looks to be healing well. It still has the speed bump from swelling. I am having a dull pain in the testicles that is uncomfortable. Is this normal? Will this go away over time, and if so, how long should I expect?

I did left inguinal hernia repair using open surgery with mesh about 1 year back.But I have consistent and recurring pain at the location of the incision. It comes and goes. Sometimes I can feel the mesh curling under my skin and there is this big lumpy bridge of scar tissue. To compound it now I have developed pubic symphsis.

Really am frustrated with this hernia repair. Wish I had never done it.

Is there anything I can do, other than repeat the surgery or knock-out the nerve to eliminate pain symptoms?

My wife and I have been in the process of moving into a new house for a few weeks now and I think that I pulled a hernia. I was lifting my wife's vanity desk and I got a sharp pain and now I can hardly pick anything up. I think that I will have to go see a doctor and get it looked at. I fear that I might need to get hernia surgery, but we will see what the doctor says.

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